Multiple causes for ischemia without obstructive coronary artery disease: not a short list.
Multiple causes for ischemia without obstructive coronary artery disease: not a short list.
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不伴有阻塞性冠状动脉疾病的缺血的多种原因：不是一个简短的列表。
DOI：
10.1161/circulationaha.115.015553
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发表时间：
2015
期刊：
影响因子：
37.8
通讯作者：
Pepine,CarlJ
中科院分区：
文献类型：
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作者：
Pepine,CarlJ
非常重要的是，这些研究人员提供了所有测试患者冠状动脉粥样硬化的 IVUS 证据，证实了我们在女性缺血综合征评估 (WISE) IVUS 子研究中的发现。 10 该信息可为未来的治疗提供方向（例如，使用他汀类药物预防动脉粥样硬化进展）。重要的是，它还提出了一个问题：动脉粥样硬化或其先前的风险状况是否可能与这些其他机制有关。当然，对于内皮功能障碍和微血管功能障碍来说也是如此。这一概念将拓宽我们对动脉粥样硬化 CAD 的传统概念，将较小的冠状血管和微循环功能障碍包括在内。为此，心外膜冠状动脉功能（通过 FFR）和微血管功能（通过冠状动脉血流速度储备 [CFVR]）之间的不一致最近引起了人们的兴趣。如果 FFR 正常，表明没有梗阻性心外膜狭窄，但 CFVR 降低，表明主要是微血管疾病，则与特别不利的预后相关。 11 相比之下，在存在流量限制性心外膜狭窄（异常 FFR）的情况下，保留微血管功能（正常 CFVR）与长期临床结果相关，与一致的正常 FFR 和 CFVR 相当。这些最近的观察结果支持冠状动脉血流评估在研究冠状动脉病理功能严重性中的关键作用。他们进一步强调了识别与冠状动脉压力和流量衍生测量之间不一致相关的病理学的重要性，以在有或没有不良结果影响的冠状动脉病理学之间提供最佳区分。换句话说，当焦点仅限于血管造影狭窄严重程度并且仅评估冠状动脉压力（例如，FFR）时，这些概念对操作者来说仍然模糊。冠状动脉微血管功能障碍越来越受到人们的认识。 12 据估计，CFVR 和 FFR 之间的不一致发生在所评估的冠状动脉狭窄的 30% 至 40% 11 中，并且源于冠状动脉微血管系统的受累（如异常 CFVR 所反映）。重要的是，与 FFR/CFVR 不一致相关的主要不良心脏事件的风险似乎主要归因于 CFVR 异常的情况。该信息强调，除了压力之外，还需要进行冠状动脉血流评估，以便对稳定型 CAD 患者进行最佳风险分层。
It was very important that these investigators provided IVUS evidence of coronary atherosclerosis in all patients tested, confirming our findings from the Women’s Ischemia Syndrome Evaluation (WISE) IVUS substudy. 10 This information could provide direction for future management (eg, statin to prevent atherosclerosis progression). Importantly, it also raises the question of whether atherosclerosis or its preceding risk conditions could be linked to these other mechanisms. Certainly, this would be true for endothelial dysfunction and for microvascular dysfunction. This notion would broaden our traditional concepts of atherosclerotic CAD to include dysfunction of the smaller coronary vessels and microcirculation. To this end, discordance between epicardial coronary function (by FFR) and microvascular function (by coronary flow velocity reserve [CFVR]) has generated recent interest. Finding a normal FFR, indicating no obstructive epicardial stenosis, but reduced CFVR, indicating predominant microvascular disease, is associated with a particularly unfavorable prognosis. 11 In contrast, preserved microvascular function (normal CFVR) in the presence of flow-limiting epicardial stenosis (abnormal FFR) has been associated with a longterm clinical outcome comparable to concordant normal FFR and CFVR.These recent observations support a critical role for coronary flow evaluation in the investigation of the functional severity of coronary pathology. They further emphasize the importance of identifying pathology associated with discordance between coronary pressure–and flow–derived measures to provide optimal discrimination between coronary pathologies with and without adverse outcome implications. Said another way, these concepts will remain obscure to operators when the focus is limited to angiographic stenosis severity and only coronary pressure (eg, FFR) is assessed. Coronary microvascular dysfunction is increasingly being recognized. 12 It has been estimated that discordance between CFVR and FFR occurs in≈ 30% to 40% of coronary stenoses evaluated11 and originates from involvement of the coronary microvasculature (as reflected by abnormal CFVR). Importantly, the risk for major adverse cardiac events associated with FFR/CFVR discordance appears to be attributable mostly to cases in which CFVR is abnormal. This information emphasizes the requirement for coronary flow assessment, in addition to pressure, for optimal risk stratification in patients with stable CAD.